Because time equals life for neurosurgeons, calls from the hospital mean the world must stop, the mind must jump start.
MY phone rings. There is only one name that still gives me goosebumps when it flashes on my mobile, especially if it’s late in the evening and I operated on a tough case earlier in the day: the ICU. I experience a roller coaster of emotions. The heart churns while the brain tries to ration between two rings and swiping right. Fear, uncertainty, confusion, despair, and, occasionally, doom, all dance within. I believe they are the same emotions my little daughters’ experience when I come home unexpectedly early and catch them glued to their iPads. In their defense, they are awesome girls.
Most often, the phone call is to inform me of the wellbeing of the patient and sometimes even to commend me on the dramatic recovery made, but there are rare instances where a post-operative patient has worsened and may require urgent intervention. While the chance of this is negligible, the mind, for some unexplainable reason, is tuned to expect the worse. The relief of knowing that everything is fine is commensurate to gobbling a spoonful of Nutella straight from the bottle.
In contrast, a phone call from the emergency department is received with enthusiasm and fervor, except if it’s a patient you have recently discharged who has returned with a complication. Most often the problem I’m called about is new, acute, and needs immediate action, something that gets the adrenaline pumping and neurons jumping. Calls from the emergency need you to be able to think fast and make life-altering decisions even in the middle of the night.
“There is a 73-year-old diabetic and hypertensive who has come to the emergency. She has a sudden onset inability to move her right arm and leg, with some slurring of speech and facial deviation for the past one hour. They stay across the road and hence have made it here so quick,” the doctor manning the casualty informs me in the early hours of that morning.
Hospitals are trained and geared to recognize a stroke when they see one, following the protocol required to treat it efficiently. A stroke is a medical emergency in which reduced blood flow to the brain results in cell death. There are two main types of stroke: ischemic, owing to lack of blood flow, and haemorrhagic, owing to bleeding. Both result in parts of the brain not functioning properly. A specialized MRI is completed within 15 minutes of the patient arriving at the hospital and the entire team assigned to take care of such a patient is alerted. Imaging is essential to differentiate the kind of stroke, as treatment differs. If the brain is damaged owing to a block in a blood vessel, treatment involves giving a clot-busting drug. This is exactly what this lady had, and she checked off all the boxes to be eligible to receive the required medication. In contrast, if you gave a blood thinner to someone who has just had a brain haemorrhage, it could be catastrophic.
We gave her the drug over an hour’s intravenous infusion, and mid-way through it, she started speaking coherently, moving her arm and leg. Her relatives could not believe their eyes considering all the gory possibilities we presented them with before taking consent to administer this expensive drug. It was like a magic show for them, akin to watching an episode of miraculous recoveries in Greys Anatomy (minus the love-making).
However, occasionally, it does happen that the drug does not work. It is most effective when given within the first four hours of the onset of paralysis, and hence our constant effort to educate people for the need to expedite coming to the emergency if their dear ones suffer from any of these symptoms.
The pneumonic to be aware of is BE FAST. If you have a sudden Balance difficulty, Eye disturbance such as blurring or double vision, Facial slurring, Arm or leg weakness, and Slurred speech, it’s Time to get to the emergency. Don’t waste any time calling a doctor home.
When the drug doesn’t produce the desired effect, we are compelled to perform an angiogram, using specialised wires and catheters inserted through the groin and guided into the blood vessels of the brain to retrieve the clot and prevent a larger area of the brain from shutting down. “You learn neurology stroke by stroke,” Charles Miller Fischer, a famous neurologist once said. Fortunately for us, we did not need plan B this time. Our lady had made an orchestrated recovery, almost as if the last two hours in her life had not occurred.
We shifted her into the ICU for overnight observation because one of the complications associated with this procedure is delayed haemorrhage, resulting in impending deterioration. I spun by the ICU to check on all my patients, a practice I follow before I leave for the day, and there she was, asking me if she could go home the next day. I reassured her by shaking her frail hand as she put the other one over my head to bless me, something grandmothers love to indulge in and which I adore.
An hour later, just as I was parking my car at home within the serene environs of my home, I got another call from the ICU. Four rings passed before I could answer, as I gingerly manoeuvred the vehicle into the gate, my head filling up with a fusillade of a few million thoughts, 99 percent of them preparing me for heading back to the hospital. “Hello,” I answered with trepidation on my hands-free. The ICU doctor’s voice reverberated through the car speakers. “Hello, sir—oh, Mazda Sir! Sorry, galti se lag gaya. (I dialed by mistake) Everything is okay. Good night, Sir.”
The writer is a practicing Neurosurgeon at the prestigious Wockhardt Hospital, South Mumbai, India. He is also an Honorary Assistant Professor of Neurosurgery at the Grant Medical College and Sir J.J. Groups of Hospitals. He specializes in the treatment of diseases of the brain and spine and advocates an approach to neurosurgery that is both balanced and proactive.Read More